Screening for Coronary Artery Calcium Screening for Coronary Artery Calcium with Computed Tomography: with Computed Tomography: Angiography and Intervention in Patients Angiography and Intervention in Patients with Scores Over 400with Scores Over 400

W. Goodwin, M. Fuseini, J. Norton, W. Goodwin, M. Fuseini, J. Norton, J.Mehta, E. Ferris; University of Arkansas J.Mehta, E. Ferris; University of Arkansas for Medical Sciences, Little Rock, AR for Medical Sciences, Little Rock, AR

HEART DISEASE HEART DISEASE IS THE LEADING IS THE LEADING CAUSE OF DEATH CAUSE OF DEATH IN THE IN THE INDUSTRIALIZED INDUSTRIALIZED WORLDWORLD

50% OF PEOPLE 50% OF PEOPLE WHO DIE FROM WHO DIE FROM HEART DISEASE HEART DISEASE HAVE AN ACUTE HAVE AN ACUTE MYOCARDIAL MYOCARDIAL INFARCTION OR INFARCTION OR SUDDEN DEATH SUDDEN DEATH AS THEIR FIRST AS THEIR FIRST PRESENTATION PRESENTATION

Over 50% of MI’s Over 50% of MI’s occur in patients occur in patients who are low or who are low or intermediate risk intermediate risk using traditional using traditional risk factorsrisk factors

Up to 30% of Up to 30% of diagnostic coronary diagnostic coronary caths are negativecaths are negative

A QUICK, EASY, A QUICK, EASY, ACCURATE, NON-ACCURATE, NON-INVASIVE TEST INVASIVE TEST FOR SIGNIFICANT FOR SIGNIFICANT CORONARY CORONARY ARTERY DISEASE ARTERY DISEASE WOULD BE HIGHLY WOULD BE HIGHLY DESIRABLE AS DESIRABLE AS HEART DISEASE HEART DISEASE HAS BECOME HAS BECOME MORE TREATABLEMORE TREATABLE

CORONARY CORONARY ARTERY ARTERY CALCIFICATION CALCIFICATION HAS BEEN HAS BEEN SHOWN TO BE A SHOWN TO BE A MARKER FOR MARKER FOR CORONARY CORONARY ARTERY ARTERY ATHEROSCLEROSATHEROSCLEROSISIS

CALCIFICATION CALCIFICATION CAN BE SEEN CAN BE SEEN WITH WITH FLUOROSCOPY FLUOROSCOPY AND ON CHEST X-AND ON CHEST X-RAYRAY

COMPUTED COMPUTED TOMOGRAPHY TOMOGRAPHY ALLOWS ALLOWS QUANTIFICATION QUANTIFICATION OF THIS CALCIUM OF THIS CALCIUM

SCORES ARE SCORES ARE BASED ON BASED ON MEASURED AREA MEASURED AREA AND PEAK CT AND PEAK CT NUMBER WITHIN NUMBER WITHIN THE BORDERS OF THE BORDERS OF EACH CORONARY EACH CORONARY ARTERY. ARTERY.

WE USED THE WE USED THE AGATSTON AGATSTON METHODMETHOD

PATIENTS WERE PATIENTS WERE SCANNED USING SCANNED USING NON-CONTRASTED NON-CONTRASTED 2.5 MM SLICES 2.5 MM SLICES THROUGH THE THROUGH THE HEARTHEART

EXAM IS EXAM IS PERFORMED PERFORMED DURING A SINGLE DURING A SINGLE BREATH HOLDBREATH HOLD

THESE STUDIES THESE STUDIES MUST BE EKG MUST BE EKG GATED IN ORDER GATED IN ORDER TO DECREASE TO DECREASE MOTION ARTIFACTMOTION ARTIFACT

SCANS ARE SCANS ARE OBTAINED AT 80% OBTAINED AT 80% OF THE R-R OF THE R-R INTERVALINTERVAL

PATIENTS WERE PATIENTS WERE SELF-REFERRED SELF-REFERRED AND AND ASYMPTOMATIC AT ASYMPTOMATIC AT THE TIME OF THE THE TIME OF THE CT SCANCT SCAN

ALL EXAMS WERE ALL EXAMS WERE DONE ON THE DONE ON THE SAME 4 DETECTOR SAME 4 DETECTOR SCANNERSCANNER

3,368 people were 3,368 people were screened between 2000 screened between 2000 and 2003and 2003

1793 men1793 men 1575 women1575 women Age : 21-92 (54 Age : 21-92 (54 ± ± 9.4 9.4

years)years) Average follow-up was Average follow-up was

16 months(3-30 16 months(3-30 months)months)

-1000

0

1000

2000

3000

4000

5000

6000

20 30 40 50 60 70 80 90 100

Age

CT

Sco

re

malesmales

031%

1-39957%

>=40012%

femalesfemales

057%

1-39940%

>=4003%

totaltotal

043%

1-39949%

>=4008%

19% of patients 19% of patients who reported who reported having diabetes having diabetes had scores over had scores over 400400

8% of the total 8% of the total population had population had scores over 400scores over 400

p<.0001p<.0001

277 people (8%) 277 people (8%) had scores over had scores over 400.400.

Of these 69 (25%) Of these 69 (25%) underwent underwent coronary coronary angiographyangiography

58/69 (84%) had a 58/69 (84%) had a coronary artery coronary artery with at least a 50 with at least a 50 % stenosis by % stenosis by angiographyangiography

44/69 (64%) had an 44/69 (64%) had an intervention intervention including:including:

AngioplastyAngioplasty Stent placementStent placement And/or coronary And/or coronary

artery bypass artery bypass graftinggrafting

In this study group In this study group there were 7 there were 7 confirmed deathsconfirmed deaths

6/7 (86%) occurred 6/7 (86%) occurred in the over 400 in the over 400 groupgroup

Mortality Mortality ≥≥ 400 = 400 = 2.2%2.2%

Mortality < 400 = Mortality < 400 = 0.03%0.03%

p<.0001p<.0001

Mortality in the group who had scores over 400 Mortality in the group who had scores over 400 and who had an intervention was 2/44 or 4.5%and who had an intervention was 2/44 or 4.5%

Mortality in the group who had scores over 400 Mortality in the group who had scores over 400 and who did not have an intervention was and who did not have an intervention was 4/233 or 1.7%4/233 or 1.7%

p=.24 (not significant) p=.24 (not significant)

We will continue to follow these patients to see We will continue to follow these patients to see if a trend develops over timeif a trend develops over time

% of subjects who had measurable calcium in specific % of subjects who had measurable calcium in specific arteriesarteries

LMCALAD

CIRCRCA

S1

10.5

43.8

27.928.4

0

10

20

30

40

50

60

70

80

90

100

Calcium score and Calcium score and angiogram results angiogram results were evaluated for were evaluated for the left main, LAD, the left main, LAD, circumflex, and right circumflex, and right coronary arteriescoronary arteries

An angiogram was An angiogram was considered positive if considered positive if there was a 50% or there was a 50% or greater stenosis greater stenosis

T-tests were T-tests were performed to performed to evaluate for an evaluate for an association between association between the calcium score in a the calcium score in a specific artery and specific artery and the angiogram results the angiogram results for that arteryfor that artery

None of the four tests None of the four tests showed a significant showed a significant associationassociation

CT CORONARY CALCIUM SCORING CT CORONARY CALCIUM SCORING DOES NOT:DOES NOT:

PREDICT WHICH SPECIFIC PREDICT WHICH SPECIFIC CORONARY ARTERIES ARE STENOTICCORONARY ARTERIES ARE STENOTIC

PROVIDE ENOUGH INFORMATION PROVIDE ENOUGH INFORMATION TO BE CERTAIN WHO DOES AND TO BE CERTAIN WHO DOES AND WHO DOES NOT NEED WHO DOES NOT NEED INTERVENTIONINTERVENTION

A HIGH CT CORONARY CALCIUM A HIGH CT CORONARY CALCIUM SCORE IS ASSOCIATED WITH:SCORE IS ASSOCIATED WITH:

DIABETESDIABETES INCREASING AGEINCREASING AGE CORONARY ATHROSCLEROSISCORONARY ATHROSCLEROSIS SIGNIFICANT LUMINAL SIGNIFICANT LUMINAL

NARROWINGNARROWING INCREASED MORTALITYINCREASED MORTALITY INCREASED CARDIAC DEATHINCREASED CARDIAC DEATH

CALCIFICATION OF CALCIFICATION OF THE CORONARY THE CORONARY ARTERIES WILL ARTERIES WILL CONTINUE TO BE CONTINUE TO BE RELEVANT BECAUSE RELEVANT BECAUSE OF ITS OF ITS RELATIONSHIP TO RELATIONSHIP TO HEART DISEASE AND HEART DISEASE AND DUE TO ITS EFFECT DUE TO ITS EFFECT ON CT ANGIOGRAPHY ON CT ANGIOGRAPHY OF THE CORONARY OF THE CORONARY ARTERIESARTERIES